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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496802052
Report Date: 10/30/2024
Date Signed: 10/30/2024 04:54:03 PM

Document Has Been Signed on 10/30/2024 04:54 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:BETSY'S II RCFEFACILITY NUMBER:
496802052
ADMINISTRATOR/
DIRECTOR:		ALICDAN, LUNINGNINGFACILITY TYPE:
740
ADDRESS:3101 BRUSH CREEK ROADTELEPHONE:
(707) 537-0399
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY: 13CENSUS: DATE:
10/30/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Luningning Alicdan, LicenseeTIME VISIT/
INSPECTION COMPLETED:
04:53 PM
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Regional Manager, Carla Nuti-Martinez, Licensing Program Manager Victoria Bertozzi, and Licensing Program Analyst Christi Coppo met with Licensee, Bot Alicdan to conduct a Non-Compliance meeting. This meeting serves as the first quarterly NCC meeting.

On of 7/31/2024 licensee agreed to be on a Non-Compliance plan. The areas of concern were identified as:
  • Administrator Duties and Plan of Operation
  • Staff Training
  • Resident and staff records
  • Resident Care and Personal Rights
  • Insufficient Staffing
  • Failure to clear deficiencies timely
  • Medication Management
  • Failure to follow through with TSP

Licensee is to ensure the following:
  • Follow through with responding to and participating with the Technical Support Program
  • Ensure compliance with areas including, but not limited to, staff training records, maintaining staff and resident records and pre-pouring of medication.
  • Ensuring personal rights of residents in care and ensuring resident needs are met.


As of today, 10/30/2024, licensee has fulfilled following through with responding to and participating with the Technical Support Program.

Continued on 809C...

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: BETSY'S II RCFE
FACILITY NUMBER: 496802052
VISIT DATE: 10/30/2024
NARRATIVE
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As of today, 10/30/2024, licensee has not ensured compliance with maintaining staff and resident records as evidenced by LPA's recent observations made during the complaint investigation conducted on 10/24/2024 and outstanding deficiencies from Annual Inspection conducted on 6/19/2024.

During investigation conducted on 10/24/2024, LPA found that two [2] staff members, S1 and S2 were not associated to the facility. This deficiency was previously cited during the annual visit on 6/19/2024 for the same two [2] staff S1 and S2. The deficiency remains outstanding as the plan of correction was not satisfied. The outstanding deficiencies from 6/19/2024 are:
· Criminal Record Clearance; 87355(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
o Civil Penalty Issued. Licensee was to submit proof of Guardian roster indicating staff were associated. This plan of correction was not satisfied as licensee submitted note stating that they were unable to associate staff members to Guardian along with staff information.

· Incidental Medical and Dental Care Services; 87465(h)(4) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label.
o Licensee was to submit in-service training on how to document centrally stored medications. This plan of correction was not satisfied as licensee submitted copy of regulation

· Incidental Medical and Dental Care Services; 87465(h)(5) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.
o Licensee was to submit submit in-service training reviewing items that are inaccessible to residents in care. This plan of correction was not satisfied as licensee submitted copy of regulation and stated that medication was not transferred between containers during LPA visit. LPA observed medications pre-poured in little dishes located in the cabinet dining room.

Continued on 809C(2)...
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: BETSY'S II RCFE
FACILITY NUMBER: 496802052
VISIT DATE: 10/30/2024
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Continued from 809C...

· Care of Persons with Dementia; 87705(f)(2) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
o Licensee was to submit in-service training reviewing regulation and items to be inaccessible to residents in care. This plan of correction was not satisfied as licensee submitted copy of regulation.

· Other Provisions Health and Safety Code; 1569.625(b)(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.
o Licensee was to submit written plan on how they will ensure annual training is conducted timely. Licensee was to also submit proof of completed annual training for all staff. This plan of correction was not satisfied as licensee submitted note stating that all staff have been signed up for CCO (Community Care Options) Training and submitted the following certificate hours for staff:
§ Elizabeth Alicdan (26 hours)
§ Erwin Alicdan (18 hours)
§ Andrea Dela Chica (14 hours)
§ Wilhelfortes “Willi” Nicdao (13 hours)

· Maintenance and Operation; 87303(e)(2) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).
o Licensee was to submit water temperature log for 10 days, starting 06/20/2024 and include location of sink and time documented. This plan of correction was not satisfied as licensee did not submit water log to CCL in either their submitted packet or by email.

Continued on 809C(3)
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: BETSY'S II RCFE
FACILITY NUMBER: 496802052
VISIT DATE: 10/30/2024
NARRATIVE
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Continued from 809C(2)...

As of today, 10/30/2024, licensee has not ensured compliance with ensuring personal rights of residents in care and ensuring resident needs are met. On 10/182024 CCL received a complaint for the facility with allegations of
  • Licensee does not ensure sufficient staffing to meet residents’ care needs.
  • Staff did not respond to resident's request for assistance in a timely manner.
  • Resident was left unattended after a fall for an extended period of time.
  • Facility has bed bugs.


All allegations were substantiated. Therefore, the licensee has not ensured compliance with ensuring personal rights of residents in care and ensuring resident needs are met.

The following regulation deficiencies are being re-cited today :
  • Criminal Record Clearance: 87355(e)
  • Incidental Medical and Dental Care Services: 87465(h)(4)
  • Incidental Medical and Dental Care Services; 87465(h)(5)
  • Care of Persons with Dementia; 87705(f)(2)
  • Other Provisions Health and Safety Code; 1569.625(b)(2)
  • Maintenance and Operation; 87303(e)(2)


Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Licensee. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with licensee and a copy of this report was given.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
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Document Has Been Signed on 10/30/2024 04:54 PM - It Cannot Be Edited


Created By: Christi Coppo On 10/30/2024 at 02:06 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: BETSY'S II RCFE
FACILITY NUMBER: 496802052

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/31/2024
Section Cited
CCR
87355(e)(2)

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87355(e) All individuals subject to a criminal record review...shall prior to working...in a licensed facility:(2) Request a transfer of a criminal record clearance as specified in Section 87355(c).
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Licensee submitted LIC9182 for CCL to associate. Deficiency cleared.
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This requirement was not met by licensee as evidenced by: failure to satifsy plan of correction for this regulation deficeincy issued on 6/19/2024, which poses a potential health, safety, and/or personal rights risk to resident in care.
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Type A
10/31/2024
Section Cited
CCR87405(a)

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(a) All facilities shall have a qualified and currently certified administrator.... The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility...
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Licensee to submit LIC500 showing what hours she is allocating for caregiving and what hours she is allocating to Admin duties. Hours reflected must be sufficient as indicated in the regulation.
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This requirement is not met by licensee as evidenced by: failure to clear deficiencies timely and deficeinces pertaining to: staff training, staff records, and resident's care needs and personal rights, which poses a potential health, safety, and/or personal rights risk to resident in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2024


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Document Has Been Signed on 10/30/2024 04:54 PM - It Cannot Be Edited


Created By: Christi Coppo On 10/30/2024 at 02:21 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: BETSY'S II RCFE
FACILITY NUMBER: 496802052

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/31/2024
Section Cited
HSC
87705(f)(2)

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87705(f)(2) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
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Facility to in-service training for all staff to review how to document centrally store medications. Training to include the following information: Date, Training Topic, Name/Job Role, and Signatures by POC due date 10/31/2024
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This requirement was not met by licensee as evidenced by: failure to satifsy plan of correction for this regulation deficeincy issued on 6/19/2024, which poses an immediate health, safety, and/or personal rights risk to resident in care.
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Type A
10/31/2024
Section Cited
CCR1569.625(b)(2)

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1569.625(b)(2)...training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training...four hours of which shall be specific to postural supports, restricted health conditions, and hospice care...
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Facility to submit proof of online training for all staff Training to include the following information: Date, Training Topic, Name/Job Role, and Signatures by POC due date of 10/31//2024
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This requirement was not met by licensee as evidenced by: failure to satifsy plan of correction for this regulation deficeincy issued on 6/19/2024, which poses an immediate health, safety, and/or personal rights risk to resident in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2024


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Document Has Been Signed on 10/30/2024 04:54 PM - It Cannot Be Edited


Created By: Christi Coppo On 10/30/2024 at 02:32 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: BETSY'S II RCFE
FACILITY NUMBER: 496802052

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/31/2024
Section Cited
CCR
87465(h)(4)

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87465(h)(4) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label
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Facility to conduct in-service training for all staff to review how to document centrally store medications. Training to include the following information: Date, Training Topic, Name/Job Role, and Signatures by POC due date of 10/31/2024
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This requirement was not met by licensee as evidenced by: failure to satifsy plan of correction for this regulation deficeincy issued on 6/19/2024, which poses a potential health, safety, and/or personal rights risk to resident in care.
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Type A
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Section Cited
CCR87465(h)(5)

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87465(h)(5) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.
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Facility to conduct in-service training for all staff reviewing that pre-poured medications are not allowed. Training to include the following information: Date, Training Topic, Name/Job Role, and Signatures by POC due date of 10/31/2024
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This requirement was not met by licensee as evidenced by: failure to satifsy plan of correction for this regulation deficeincy issued on 6/19/2024, which poses a potential health, safety, and/or personal rights risk to resident in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2024


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Document Has Been Signed on 10/30/2024 04:54 PM - It Cannot Be Edited


Created By: Christi Coppo On 10/30/2024 at 04:34 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: BETSY'S II RCFE
FACILITY NUMBER: 496802052

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/31/2024
Section Cited
CCR
87303(e)(2)

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87303 Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C)..
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Licensee to submit a water temperature log for the next 10 days. Temperature to be checked twice a day for all sinks starting on 06/20/2024. Log to include location of sink and time documented. Log to be submitted to CCL for review and approval by POC due date 10/31/2024
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Based on observations made, the Licensee did not comply with the section cited above. 7 of 13 facility sinks were found to be out of Title 22 regulations of 105F to 120F measuring between 120.5F and 126.8F. This poses a potential health, safety or personal rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2024


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